29 February 2012

The earliest memory I have of having music of my own was this album. I was maybe eight (?) and my older cousin gave me this and also Simon & Garfunkel's "Bookends." They were real vinyl, of course, and I can still sing all the songs from both by memory.

Lest you think my cousin was a bad influence, by the time I was twelve, he took me to see the Clash live and later, PIL. Whether that was a good thing or bad, I let you be the judge.

21 February 2012

My family includes four of the 49.1 million uninsured people in the United States. I’ve comforted myself that we couldn’t afford private insurance, which we can’t, but at least we were all relatively healthy and never seemed to have problems. [...]

But recently my mindset has become affected by our position. I tell my kids not to do things that I certainly enjoyed doing as a kid, like don’t climb high on trees, run a little slower on the trail, watch out for roots and stones! It’s not just the usual parental concern either. I’m consciously thinking “oh my god, I cannot afford to fix them if they get broke!”.

This is the luxury gap between the between the 20% of nonelderly americans who are uninsured and the rest. The luxury is, of course, being able to just walk into a doctor’s office and see them at the appropriate times. It is easy to discount this minority since most are at or near the poverty line. But many of the uninsured are like myself and just can’t seem to make the numbers work for a family of four each month by adding on private individual (i.e. non-group discounted) health insurance. [...]

By Tuesday we weren’t left with any choice. My son had just gotten out of a bath and though he wasn’t cold, his hand and his feet were blue. I’d never seen it like that before. My wife laid it down and we were going to the Urgent Care. We all got dressed and heading over there early. He was miserable, crying in pain cause he couldn’t get enough oxygen. We were scared that we might have waited too long. [...]

Most of the uninsured in this country aren’t lazy, freeloading hobos who don’t wanna work. They span a wide variety of demographics. As a 30 something, white male with advanced college degree who works full time as a self-employed consultant and writer are you surprised that I cannot afford health insurance for my family? In fact, the majority of uninsured are in my age range and are full or part time workers earning incomes above 100% the federal poverty level.

The good news is that his son got better. The bad news is that his care was a couple of orders of magnitude more expensive than it might have been if they'd had better access to care, and that his son's life was put into jeopardy by their necessary reluctance to seek out care. Adding insult to injury is that this family will probably have any financial reserve they possess wiped out by what should have been a minor illness.

And these aren't dirty cigarette-smoking, cell-phone buying scumbag poor people who deserve their fate (the caricature of the uninsured found most typically on libertarian blogs). This guy holds an advanced science degree and this family is firmly in the middle class. They're just unlucky enough to have to buy non-group plan insurance in the pre-ACA marketplace.

The ACA — if it goes into effect — will mitigate this. The health insurance exchanges will regulate individual health insurance plans, guarantee that no person or family will be rejected due to prior history, and make it easier for families to shop for and purchase insurance. The subsidies will make insurance more affordable on a sliding-scale basis. Bringing everybody (or nearly so) into the system will make insurance cheaper for all of us.

The ACA isn't perfect. At best it's a start. There may not be death panels, but there's plenty there not to like. You've got the mandate (for the record, I'd be fine with ditching the mandate if there were another effective method to encourage healthy people to buy in — lock-out periods or late-entry penalties or what have you). There's no public option to force insurers to compete honestly. ACOs may not do anything to bring down costs. But for Kevin Zelnio and his family and the many other families in similar situations, who desperately want insurance but cannot afford it, ObamaCare provides them with a ticket to enter into the system. It's a pity that it's gotten so polarized that we can't move on and get to work on fixing deficiencies, improving what we've got, rather than refighting the scorched earth campaigns of 2009.

17 February 2012

Eva V is the daughter of some very close friends of mine. Her dad is a pediatrician and her mom is a pediatric oncologist, so kid's health and kid's cancer are topics with which she is very familiar. Her dad has participated in the St Baldrick's fundraiser for pediatric cancer research for the last several years, and this year Eva has decided to shave her head in support of pediatric cancer as well!

She is ten years old, and I've got to hand it to any ten year old girl who's brave enough to go bald for this cause.

I won't be shaving this go around — I've got a case of fatigue after all my family's been through this year, but I will be back next year. So if you are someone who's inclined to support the St Baldrick's Foundation against kid's cancer, or if you just want to support a brave young girl, then by all means please wander over to her donor page and toss her a couple of bucks!

16 February 2012

As I spoke to her before the operation to get informed consent, the patient ran her fingers across her short hair, only now starting to grow back after her having completed her chemotherapy a few weeks ago. As I've found with many women whose hair is just starting to reappear, like the soft coat of a short-haired puppy, she looked good--better than I remembered her with hair. Indeed, it never ceases to amaze me how many women can look so good at this point in their course, where they have what looks like a Marine-style buzzcut. Maybe it's just me, or maybe it's because women who reach this stage almost invariably seem so full of life; they've faced down death and their worst fears, and come out intact, if not unscathed. And this time, the patient was elated at having this procedure. Indeed, she was practically giddy, happier than I had ever seen her. She had a glow that, if I believed in Reiki, might have interpreted as a her life energy becoming visible. I knew why she was so happy.I was going to remove her port.

It happens to be relevant because Liza got her port removed today!

And Orac was, of course, correct, in that it is a huge milestone. It officially marks the day when her primary breast cancer treatment ends and she enters the "No Evidence of Disease" monitoring stage. Which, as we have reason to hope, will transition to the "cured" stage soon enough.

Well, I'd blog more but we are putting together a party to celebrate — and to thank all the members of our community and family who helped us over the last 14 months, so I have some work to do!

10 February 2012

My father's big brother, Tony, died this morning from emphysema at the age of 75. He passed peacefully with his family by his side. He was on hospice for the past few months, which was quite a blessing.

He was quite a character. A USAF vet, early beatnik (supposedly once travelled with Kerouac), merchant marine and railroad man, he was a true cornball and raconteur. He always had a line ready for the laugh, the cheesier the better. When he was with the railroad, he had business cards made up describing himself as a "hobo for hire."

I feel bad for my dad — they were terribly close. I can't imagine what it's like to lose your brother after seven decades.

At any rate, he was a true American original, and he'll be missed. We won't see his like again soon.

02 February 2012

Last Monday, as is so common, I got an email from one of the several medical organizations of which I am a member. This was a fundraising pitch, and I can't recall the details, but it contained the usual breathless rhetoric regarding how important their advocacy efforts are to fix the SGR, enact tort reform, save the practice of medicine, ensure domestic peace and tranquility, yadda yadda yadda...

Honestly, I don't even read these things any more before I hit delete, and I have actually developed a blind spot over the text where they hysterically predict catastrophe and doom. But this caught my eye — tort reform? Who's still talking about that as a priority? Mostly because it's a pipe dream that couldn't get through a republican congress with a republican president. In this day and age it's a dead letter. But also because I kind of thought the medical malpractice crisis was over.

I'm so old now that I've been through a full cycle of the boom-and-bust in med mal. When I came into practice, insurance rates were low, and then they spiked, nearly driving our practice out of business. It was horrible. Several local groups went under, and several others were hit with huge costs as their insurers left the market or went belly-up. Ugly times. But also, long ago, and the world looks very different now. Recently we've had no trouble getting multiple carriers to bid on our professional liability insurance, and at competitive rates. We are shifting towards a self-insurance model and currently enjoying the lowest insurance costs in well over a decade.

So I got wondering -- what is really going on in medical malpractice these days? Are real numbers available? The answer turned out to be fairly difficult to find. But a nerd with a computer and a couple of days off work can be a dangerous thing. So I did some legwork (with the help of Austin Frakt and Aaron Carroll of The Incidental Economist, among others) and I was able to come to some decent conclusions.

I had a little trouble reconciling some of the variation in the data sources. For example, the median loss for a closed medical malpractice case in 2010 was $200,000 according to the PIAA, and $135,000 according to the NPDB. This refers to the amount paid to the claimant, whether by judgement or settlement, and excludes the cost of case management and defense. This variation was consistent across the board -- for all cost figures, the PIAA numbers were 15-30% higher. I am not sure why this would be. Not all carriers report to the PIAA; its dataset is much smaller, including only about 20% of all paid claims, so there may be a sampling bias at play. Payments made to claimants other than insurance payments would not be recorded in the PIAA data, and smaller insurers (or self-insured physicians) might be more tenacious in defending and thus the smaller payments might be excluded from that claimset. I would tend to view the NPDB numbers as more definitive. Still, the trends correlated well enough that I could draw some reasonable conclusions from the data. Additionally, the NPDB, which casts the wider net, gave better data on the total volume of cases, and the PIAA data had good numbers on the cost of defense.

The top line conclusion:

Medical malpractice costs are down quite a bit — about 35% from their 2001 peak:

This includes all professional liability claims against all individual providers: physicians, dentists, nurse practitioners, nurse anesthetists, etc. The vast majority is physician cost. I factored in the costs of defense as well, since that generally contributes about 25% of the cost of the median case. Note that the scale of the graph is adjusted to highlight the trend. Again, I suspect the PIAA line significantly overstates the actual cost, but I included it to show its trendline against the NPDB trend. I also note that the 2001-2003 peak in medical malpractice insurance rates did correlate with a historic high in malpractice losses. (At the time there was much speculation that the insurance companies were exploiting their rate-setting power to recoup reserve losses from the stock market implosion.) The actual cost is probably slightly higher since claims management and defense costs for cases the physician won are not included.

The decline in costs is not driven by increased losses per claim, which have remained remarkably stable over time:

Note that these costs are adjusted for inflation, and exclusive of defense costs. The median claim loss was in fact highly stable at the above-noted levels ($135,000), but the average cost was more reflective of real-world experience, I thought, since it shows the effect of the occasional very large verdicts/settlements. Which as it turns out, do not seem to be on the rise; quite the opposite.

However, the claim frequency is down dramatically. This seems to be the major driver of the decreased cost:

So what we are seeing is a 40% reduction in the frequency of claims which result in payment to a patient. Not claims made, but closed claims with payments. Important distinction.

What's the driver of this trend? I have no idea. There could be fewer cases being filed, or physicians and insurers could be more aggressive in defending claims. Tort reforms were enacted in a couple of states, but I do not think that has contributed enough to change the national picture.

One suspicion I may have is that the lawyers who specialize in med mal cases may simply be more selective in the cases they are willing to take to trial. The costs of defending a malpractice claim has risen from $35,000 to about $50,000, and claims which go to trial cost about $150,000. If the plaintiff's costs are anywhere near that scale, it's a very expensive and risky proposition for a plaintiff's attorney to front that sort of money in the hope that they will win at trial. Since the very few cases which go to trial (about 8%) result in a defense verdict the vast majority of the time (~90%), it's quite possible that many lawyers are discouraged from gambling on a case which is anything other than a sure win. It's also possible that physicians (and their insurers) have become more savvy in settling losing claims quickly and at less cost.

There's a lot more to glean from the data, and when I get a chance I intend to break out the state-level distributions. I'm curious to see whether the "crisis" states are really in crisis, and how well state-level premiums really correlate with the case rates. But, in summary, it is accurate to say that malpractice cases and costs are significantly down across the nation. I would add, as a cautionary note, that the history of medical malpractice is quite cyclical and unpredictable, and it's highly likely that in the future we may —will — see another crisis when rates spike.

But for now, make hay while the sun shines!

I will post the raw data for those who are curious when I get a chance to clean it up a bit -- it's right now all helter-skelter in a huge, ugly spreadsheet.

You know, writing about poor old Boomerang Bill made me think of another notorious alcoholic we used to see on a regular basis when I was a resident. I seem to think that I've written about this guy before, but I can't find him in a quick scan of my archives.

This fellow was another who was frequently found by EMS slumped on the ground under a bar stool. We knew him well. He was surprisingly high-functioning, though, in that he managed to maintain some semblance of a job and a stable social situation. He even had family that would sometimes come and get him from the ER, which is pretty rare for a hard-core alcoholic. He didn't talk much (a welcome trait in an alcoholic frequent flyer) so he got nicknamed "Silent Bob," after the character in Clerks.

Like many heavy drinkers, Silent Bob was tough, and near indestructible. Something about really pickling yourself over many years can for some people give them the ability to survive the lethal insults of physiology. I've seen the same phenomenon at VA hospitals as well. But this guy took the cake.

Perforated gastric ulcer: Survived

Necrotizing pancreatitis: Survived

Subdural hematoma: Survived

Nothing could touch him, and he kept coming back, over and over.

One memorable week, he was brought in by the same EMS crew three times in a row. The first time they found him passed out on the sidewalk outside a bar. The next day he was trespassed in the public library but was too drunk for jail. A couple of days later he was found passed out in the firehouse underneath the fire engine! He had crawled in there when the door was open and fallen asleep under the fire truck itself. They nearly ran him over heading out on a call, but someone noticed his legs sticking out before they drove away. Fortunate for him.

So a few days later, when the same EMS crew was called out and found Silent Bob passed out under the railroad viaduct, they weren't too surprised, and just bundled him up and brought him back in. They did not notice that he was not moving his arms or legs, because, well, he was passed out and not expected to be moving much of anything. It turned out that Silent Bob had fallen off the viaduct and had a horrible C4-5 fracture/dislocation. I used to have the images somewhere — they were impressive.

So once we figured out that he wasn't "just drunk," which is incidentally the most dangerous diagnosis it is possible to have in an ER, we got him admitted to neurosurgery. They did some sort of procedure; I wasn't clear on the details. What was memorable was that a few days later, word filtered through the ER that Silent Bob had walked out of the hospital against medical advice. First of all, how shocking is it that he was walking at all? Second, who the hell leaves the hospital AMA with a broken neck? He apparently had some residual weakness in his lower extremities and still had a halo in place, but he was not going to hang around the goddamned hospital where they wouldn't let you have a drink, was he?

So, another bullet dodged, another lethal diagnosis to add to the list of things he had survived.

We saw Silent Bob in & out of the ER for the next year or so. He never followed up in neurosurgery clinic, but when he came in we'd call them down to adjust, and eventually remove, his halo. He needed a cane to walk, but otherwise had survived his most recent brush with the reaper very well.

Finally, one day, he was brought in dead by the same medic crew who had seen him so many times before. Apparently, Silent Bob was passed out on a park bench when he was witnessed to have been hit by lightning. Really. EMS did their bit, and we did our bit, but his heart did not restart and that was the end of Silent Bob.

One of my attendings reflected, and eulogized Bob after we had terminated the resuscitation. "You know, this was probably the toughest mother fucker I have ever known. He shrugged off more disease than any of us mere mortals ever will. You want to know how tough this guy was? It took an act of God to kill Silent Bob. We won't see his like again soon."

01 February 2012

One thing which has long pissed me off about the christianist faction in US politics, with regard to their never-ending quest to impose their definition of "life" onto everybody else in the country, is the way they put their ideology and their theology above the actual health and lives of real, actual, living and breathing women. Their belief in a magical spirit force in a clump of nonsentient cells is important enough they they are willing to lay waste to the rights, privacy, and also the health of the women who sinfully misuse their ladyparts.

For years, the symbol that women's health activists have used to communicate this was the coathanger -- the implication that if abortion is driven underground then women will die from back-alley botched septic abortions. I always thought that was a bit over-the-top, though: too hypothetical and unlikely to carry much punch nowadays. It may have had more relevance in the '70s, when the era of illegal abortion was fresher in people's minds.

But now, if you are looking for real, actual evidence of how the radical christian right is willing to put women's lives at risk to save the spirit babies, look no further than the war on Planned Parenthood. Over the last two years, it has come under constant assault from conservative politicians, seeking to cut off its funding and force it to wither on the vine. The tactic is simple, and possibly effective: if you can kill or cripple an institution which is a major abortion provider, there will be fewer abortions. If all you care about are abortions, the math works out fine.

It is important to remember, though, that Planed Parenthood does way more than just abortions. They are a comprehensive provider of women's health services, primarily to low-income women who cannot afford to see a primary doctor or a gynecologist. Abortions are, in fact, a tiny minority of what Planned Parenthood does!

Planned Parenthood is caricatured in right-wing circles as no more than an abortion mill. As you can see, however, of all the patient contacts Planned Parenthood has, only 3% are for abortions. 35% are for STD screening and treatment, 35% are contraceptive, 16% are cancer prevention and screening. They perform nearly a million breast cancer screening exams annually, and a similar number of screening tests for cervical cancer. (source: PDF)

In fact, Planned Parenthood estimates that they prevent over 250,000 abortions annually, as a result of their contraceptive services preventing nearly 600,000 unintended pregnancies. Never mind the number of cases of tubo-ovarian abscesses and ectopic pregnancy they prevent by treating STDs and the number of lives they save through their cancer screening services -- particularly cervical cancer screenings.

Now, if you kill Planned Parenthood by pulling its federal funding, as Congressional Republicans tried, or by restricting its access to medicaid clients, as Indiana Republicans tried, or by burdening it with onerous and prohibitive pointless regulations, as Kansas tried, then you could possibly prevent 300,000 abortions a year. The consequence to that, however, would be that millions of women who have no other alternative would lose access to these other services, and some of them would die as a result of that.

That's not being hysterical, just simply pointing out the fact that policy decisions have consequences and some of those are what are drily euphemized in the medical literature as "increased morbidity and mortality," which is to say -- increased sickness and death. And to the true believers, the holy warriors (I won't say jihadists) of the anti-abortion movement, they are OK with those collateral human costs.

Planned Parenthood is an important provider of health care for women, particularly vulnerable women. And it's important for those of us in the health care community to stand up in its defense against the religious extremists who want to shut it down.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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